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Alois Dvorzak and his wife

Nurses
were “shocked” when an 84 year old man arrived at a London hospital chained
to a security guard, an inquest into the death of Alois Dvorzak heard today.
The six foot long chain was removed only after he stopped breathing five hours
later.

Dvorzak,
a retired electrical engineer, was rushed to Hillingdon Hospital in an ambulance after
complaining of chest pains at Harmondsworth immigration detention centre, near Heathrow.

The
UK Border Agency had kept the elderly Canadian man detained for a fortnight
after denying him entry at Gatwick airport.

Security
staff at Harmondsworth handcuffed Dvorzak for hospital visits because he was an
“escape risk”, the inquest has heard.

Ambrosino
told the inquest he had challenged the security guards about the restraints,
but was told it was Home Office policy.

“I
felt it was unnecessary,” Ambrosino said. “It was an elderly person, he wasn’t
going to run away.”

It
was the first and last time the paramedic had seen a detainee chained to a
guard in an ambulance.

Dvorzak
was “very angry and upset” in the ambulance, pulling off an electrode from his
chest, the jury at West London Coroner's Court heard. “He became agitated and
grabbed [electrode] dots off his chest and threw them on the floor,” Ambrosino
recalled.

Senior
Coroner Chinyere Inyama asked: “Having seen this agitation, did it revise your
view on the need for the chain?”

“Absolutely
not,” the paramedic replied.

Dvorzak
arrived in London from Canada in January 2013. He was trying to reach family in
Slovenia. UK immigration officers were concerned that he was unfit to carry on
his journey unaccompanied and wanted to send him back to Canada.

“I
haven’t got much time, I need to go to see my family,” a tearful Dvorzak told
Vernon Simmonds-Dunne, the Older Persons Liaison Officer at Harmondsworth, days
before he died.

Simmonds-Dunne
told the inquest that Dvorzak “seemed in
a world of his own”. He was always smartly dressed, in the same clothes, as if
he were “ready to carry on his journey”, the officer recalled.

The
jury heard that the Older Persons Liaison role had lapsed
for twelve months and has only recently resumed. There are currently
three detainees over the age of 65 detained at Harmondsworth.

Simmonds-Dunne,
the incumbent, told the coroner he was not aware of the older persons welfare
clinic at the centre and would “definitely look into it”.

At
the time of Dvorzak’s death, Harmondsworth held 615 detainees and was the
largest removal centre in Britain. It was run for the Home Office by GEO Group, the American prisons company.

Dr Iain Brew, an independent clinical
assessor, told the inquest that inspections of
Harmondsworth had “identified a number of failings including in
healthcare”. He said detention officers have “mentioned a lack of mental
healthcare as a concern and to some extent continue to do so”.

Dvorzak
was refusing to take a dozen medications for his mental health and heart
problems. “That was medication he should have been taking and as we know he was
not taking it. That must have contributed to his demise,” said Brew.

He
carried out a review of all medical records following Dvorzak’s death and found
that one clinician, Dr Asim Navqi, had said Dvorzak was “at high risk of death
in detention”. Brew added: “And sadly he turned out to be right.”

Brew
found that “overall, health staff had offered a generally high standard of care
and I thought this care was equivalent to what he would have received in the
community”. However, more efforts should have been made to find out about
Dvorzak’s medical history in Canada, he said.

Emma
Donoghue, head of primary care in Harmondsworth, said staff now had to complete
new risk assessment forms before handcuffing detainees. However, she said the
“principles are the same, although the forms may look slightly different”.
Donoghue said there was an opportunity in the old forms for healthcare staff to
recommend that Dvorzak was not restrained, but they had failed to do so.

The
coroner said that there was “something akin to a Chinese walls situation” at
Harmondsworth, with security and healthcare staff not sharing vital information
about detainees. Donoghue said a complex case meeting group was set up twelve
months ago so all the stakeholders at Harmondsworth could share information
about vulnerable detainees.

A
juror asked Donoghue if these changes had been introduced as a result of Dvorzak’s
death. “There’s lots of reasons. Performance indicators and contractual
requirements have changed. Contractors must now be able to evidence things in a
more robust way,” Donoghue replied.

The
coroner said the jury had heard “conflicting” evidence about the system in
place for training locum doctors at Harmondsworth at the time of Dvorzak’s
death.